NIHR Signal Fluoride varnish every six months helps protect children’s permanent teeth from decay

Published on 1 August 2017

Fluoride varnish and fissure sealant are equally good at preventing tooth decay on children’s first permanent back teeth when applied to six or seven year olds in South Wales. Six applications of fluoride varnish were less expensive, by about £68 per child, for the NHS at 36 months compared to applying the more expensive fissure sealant.

Children’s permanent back teeth are particularly vulnerable to decay when they first come through. The pitted biting surface can make these teeth difficult to keep clean to prevent decay.

This NIHR-funded trial looked at two interventions to prevent decay: fluoride varnish applied six times every six months at school and a syntheticresin, protective polymer coating, applied once and replaced if needed.

This large, UK-based trial supports NICE recommendations to apply fluoride varnish to children’s teeth as part of a school-based community dental programme in areas of high need with children at risk.

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Why was this study needed?

The NHS spends £30 million per year removing decayed teeth in children and there is a strong link between socioeconomic status and rates of decay.

Children’s first teeth start coming through around six months, these “baby teeth” are then replaced by permanent teeth. Around six years old children’s back teeth, the first permanent molars, come through. These do not replace baby teeth. Maintaining good dental hygiene and regular brushing with fluoride toothpaste is important in preventing decay and prolonging the life of teeth.

Poor oral health can have a big impact on people’s lives as it leads to pain, tooth loss, affects daily tasks such as eating and speaking, and can reduce people’s confidence in social situations. Children from socially and economically deprived backgrounds are at increased risk, so this study looked at two different methods to protect the first permanent molars from decay in an area where children were at high risk.

What did this study do?

This randomised controlled trial included 1,015 children aged six and seven years old. In addition to their usual toothbrushing, children either had a fluoride-rich varnish applied to their first permanent molar teeth or a hard resin fissure sealant applied to provide a protective layer.

The varnish was reapplied at six, 12, 18, 24 and 30 months. Fissure sealant was checked every six months and repaired if damaged. The intervention was delivered by a community dental service in an area of high socioeconomic deprivation in South Wales.

The health professionals assessing the children’s teeth for decay were not informed of which treatment they had received, but fissure sealant is visible on the teeth so they may have been aware of the treatments that each child had received. The trial included sufficient numbers of children for us to feel confident in its findings and 82% of the children were assessed at 36 months.

What did it find?

  • There was no difference in the proportion of first permanent molar teeth that developed decay (7.5%) in both the varnish and fissure sealant groups.
  • The pitted, biting surfaces of teeth were more likely to develop decay than smooth surfaces (6.4% compared to 1.1%) after 36 months. There was no significant difference between the varnish and fissure sealant.
  • Overall fluoride varnish was cheaper to use than fissure sealant (£432 compared to £500) and created a significant cost saving for the NHS of £68.13 (95% confidence interval [CI], £5.63 to £130.63) per child compared to fissure sealant at 36 months.
  • Children were asked to indicate how happy they were at the start and end of the trial, using a visual scale of faces showing different emotions or feelings. The children in the fluoride varnish group were significantly more likely than the fissure sealant group to say they were happy at the start of the trial, but were significantly less likely to report being happy at the end of the trial. Most of the children completed the trial, which suggests that the treatment was generally acceptable.

What does current guidance say on this issue?

NICE 2014 guidelines recommend that local authorities undertake a needs assessment to identify areas where children are at a high risk of poor oral health. In these areas NICE recommends that authority’s commission supervised tooth brushing schemes in nurseries and primary schools.

Where a tooth brushing scheme is not feasible, NICE recommends a community-based programme of applying fluoride varnish at least twice a year in primary schools. Ideally – where resources permit – NICE recommends commissioning both tooth brushing and fluoride varnish programmes.

What are the implications?

Fluoride varnish and fissure sealant were similarly effective in preventing tooth decay in six and seven year old children’s first permanent teeth. These interventions were effective amongst children with high social and economic deprivation, who are particularly at risk of tooth decay.

Fluoride varnish was cheaper than fissure sealant and saved the NHS more money. Although the children were less happy with the varnish than the fissure sealant, most continued to the end of the trial, suggesting that the treatment was acceptable even if not entirely pleasant.

The findings of this trial support NICE recommendations to use fluoride varnish as part of a school-based community dental programme in areas of high need.

Citation and Funding

Chestnutt IG, Hutchings S, Playle R, et al. Seal or Varnish? A randomised controlled trial to determine the relative cost and effectiveness of pit and fissure sealant and fluoride varnish in preventing dental decay. Health Technol Assess. 2017;21(21):1-256.

This project was funded by the National Institute for Health Research Health Technology Assessment (project number 08/104/04).

Bibliography

The ADA Division of Communications. Tooth eruption: the permanent teeth. JADA. 2004;137:127.

Cleveland Clinic. Teeth eruption timetable. Cleveland (OH): Cleveland Clinic; 2014.

NHS Choices. Children’s teeth. London: Department of Health; 2015.

NICE. Oral health: local authorities and partners. PH55. London: National Institute for Health and Care Excellence; 2014.

NICE. Dental checks: intervals between oral health reviews. CG19. London: National Institute for Health and Care Excellence; 2004.

Why was this study needed?

The NHS spends £30 million per year removing decayed teeth in children and there is a strong link between socioeconomic status and rates of decay.

Children’s first teeth start coming through around six months, these “baby teeth” are then replaced by permanent teeth. Around six years old children’s back teeth, the first permanent molars, come through. These do not replace baby teeth. Maintaining good dental hygiene and regular brushing with fluoride toothpaste is important in preventing decay and prolonging the life of teeth.

Poor oral health can have a big impact on people’s lives as it leads to pain, tooth loss, affects daily tasks such as eating and speaking, and can reduce people’s confidence in social situations. Children from socially and economically deprived backgrounds are at increased risk, so this study looked at two different methods to protect the first permanent molars from decay in an area where children were at high risk.

What did this study do?

This randomised controlled trial included 1,015 children aged six and seven years old. In addition to their usual toothbrushing, children either had a fluoride-rich varnish applied to their first permanent molar teeth or a hard resin fissure sealant applied to provide a protective layer.

The varnish was reapplied at six, 12, 18, 24 and 30 months. Fissure sealant was checked every six months and repaired if damaged. The intervention was delivered by a community dental service in an area of high socioeconomic deprivation in South Wales.

The health professionals assessing the children’s teeth for decay were not informed of which treatment they had received, but fissure sealant is visible on the teeth so they may have been aware of the treatments that each child had received. The trial included sufficient numbers of children for us to feel confident in its findings and 82% of the children were assessed at 36 months.

What did it find?

  • There was no difference in the proportion of first permanent molar teeth that developed decay (7.5%) in both the varnish and fissure sealant groups.
  • The pitted, biting surfaces of teeth were more likely to develop decay than smooth surfaces (6.4% compared to 1.1%) after 36 months. There was no significant difference between the varnish and fissure sealant.
  • Overall fluoride varnish was cheaper to use than fissure sealant (£432 compared to £500) and created a significant cost saving for the NHS of £68.13 (95% confidence interval [CI], £5.63 to £130.63) per child compared to fissure sealant at 36 months.
  • Children were asked to indicate how happy they were at the start and end of the trial, using a visual scale of faces showing different emotions or feelings. The children in the fluoride varnish group were significantly more likely than the fissure sealant group to say they were happy at the start of the trial, but were significantly less likely to report being happy at the end of the trial. Most of the children completed the trial, which suggests that the treatment was generally acceptable.

What does current guidance say on this issue?

NICE 2014 guidelines recommend that local authorities undertake a needs assessment to identify areas where children are at a high risk of poor oral health. In these areas NICE recommends that authority’s commission supervised tooth brushing schemes in nurseries and primary schools.

Where a tooth brushing scheme is not feasible, NICE recommends a community-based programme of applying fluoride varnish at least twice a year in primary schools. Ideally – where resources permit – NICE recommends commissioning both tooth brushing and fluoride varnish programmes.

What are the implications?

Fluoride varnish and fissure sealant were similarly effective in preventing tooth decay in six and seven year old children’s first permanent teeth. These interventions were effective amongst children with high social and economic deprivation, who are particularly at risk of tooth decay.

Fluoride varnish was cheaper than fissure sealant and saved the NHS more money. Although the children were less happy with the varnish than the fissure sealant, most continued to the end of the trial, suggesting that the treatment was acceptable even if not entirely pleasant.

The findings of this trial support NICE recommendations to use fluoride varnish as part of a school-based community dental programme in areas of high need.

Citation and Funding

Chestnutt IG, Hutchings S, Playle R, et al. Seal or Varnish? A randomised controlled trial to determine the relative cost and effectiveness of pit and fissure sealant and fluoride varnish in preventing dental decay. Health Technol Assess. 2017;21(21):1-256.

This project was funded by the National Institute for Health Research Health Technology Assessment (project number 08/104/04).

Bibliography

The ADA Division of Communications. Tooth eruption: the permanent teeth. JADA. 2004;137:127.

Cleveland Clinic. Teeth eruption timetable. Cleveland (OH): Cleveland Clinic; 2014.

NHS Choices. Children’s teeth. London: Department of Health; 2015.

NICE. Oral health: local authorities and partners. PH55. London: National Institute for Health and Care Excellence; 2014.

NICE. Dental checks: intervals between oral health reviews. CG19. London: National Institute for Health and Care Excellence; 2004.

Seal or Varnish? A randomised controlled trial to determine the relative cost and effectiveness of pit and fissure sealant and fluoride varnish in preventing dental decay

Published on 28 April 2017

Chestnutt I G, Hutchings S, Playle R, Morgan-Trimmer S, Fitzsimmons D, Aawar N, Angel L, Derrick S, Drew C, Hoddell C, Hood K, Humphreys I, Kirby N, Lau T M M, Lisles C, Morgan M Z, Murphy S, Nuttall J, Onishchenko K, Phillips C, Pickles T, Scoble C, Townson J, Withers B & Chadwick B L.

Health Technology Assessment Volume 21 Issue 21 , 2017

Background Fissure sealant (FS) and fluoride varnish (FV) have been shown to be effective in preventing dental caries when tested against a no-treatment control. However, the relative clinical effectiveness and cost-effectiveness of these interventions is unknown. Objective To compare the clinical effectiveness and cost-effectiveness of FS and FV in preventing dental caries in first permanent molars (FPMs) in 6- and 7-year-olds and to determine their acceptability. Design A randomised controlled allocation-blinded clinical trial with two parallel arms. Setting A targeted population programme using mobile dental clinics (MDCs) in schools located in areas of high social and economic deprivation in South Wales. Participants In total, 1016 children were randomised, but one parent subsequently withdrew permission and so the analysis was based on 1015 children. The randomisation of participants was stratified by school and balanced for sex and primary dentition baseline caries levels using minimisation in a 1 : 1 ratio for treatments. A random component was added to the minimisation algorithm, such that it was not completely deterministic. Of the participants, 514 were randomised to receive FS and 502 were randomised to receive FV. Interventions Resin-based FS was applied to caries-free FPMs and maintained at 6-monthly intervals. FV was applied at baseline and at 6-month intervals over the course of 3 years. Main outcome measures The proportion of children developing caries into dentine (decayed, missing, filled teeth in permanent dentition, i.e. D4–6MFT) on any one of up to four treated FPMs after 36 months. The assessors were blinded to treatment allocation; however, the presence or absence of FS at assessment would obviously indicate the probable treatment received. Economic measures established the costs and budget impact of FS and FV and the relative cost-effectiveness of these technologies. Qualitative interviews determined the acceptability of the interventions. Results At 36 months, 835 (82%) children remained in the trial: 417 in the FS arm and 418 in the FV arm. The proportion of children who developed caries into dentine on a least one FPM was lower in the FV arm (73; 17.5%) than in the FS arm (82, 19.6%) [odds ratio (OR) 0.84, 95% confidence interval (CI) 0.59 to 1.21; p = 0.35] but the difference was not statistically significant. The results were similar when the numbers of newly decayed teeth (OR 0.86, 95% CI 0.60 to 1.22) and tooth surfaces (OR 0.85, 95% CI 0.59 to 1.21) were examined. Trial fidelity was high: 95% of participants received five or six of the six scheduled treatments. Between 74% and 93% of sealants (upper and lower teeth) were intact at 36 months. The costs of the two technologies showed a small but statistically significant difference; the mean cost to the NHS (including intervention costs) per child was £500 for FS, compared with £432 for FV, a difference of £68.13 (95% CI £5.63 to £130.63; p = 0.033) in favour of FV. The budget impact analysis suggests that there is a cost saving of £68.13 (95% CI £5.63 to £130.63; p = 0.033) per child treated if using FV compared with the application of FS over this time period. An acceptability score completed by the children immediately after treatment and subsequent interviews demonstrated that both interventions were acceptable to the children. No adverse effects were reported. Limitations There are no important limitations to this study. Conclusions In a community oral health programme utilising MDCs and targeted at children with high caries risk, the twice-yearly application of FV resulted in caries prevention that is not significantly different from that obtained by applying and maintaining FSs after 36 months. FV proved less expensive. Future work The clinical effectiveness and cost-effectiveness of FS and FV following the cessation of active intervention merits investigation. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 21. See the NIHR Journals Library website for further project information.

Expert commentary

Tooth decay is the commonest disease of childhood. Children living in disadvantaged communities are more likely to develop decay and suffer its consequences, such as toothache and tooth extraction. Children from poorer families are less likely to attend the dentist than children from well-off backgrounds and so school-based programmes to prevent decay are a good way of reaching disadvantaged children.

Fluoride varnish and fissure sealants are the main interventions used to prevent decay and have similar performance. In a time of severe pressure on health budgets, as fluoride varnish is slightly cheaper, a prevention programme using this intervention will be able to reach more children.

Martin Tickle, Professor of Dental Public Health and Primary Care, University of Manchester